Dietary Supplement Questionnaire

Transcription

1 Dietary Supplement Questionnaire Please ensure you sign the consent form prior to completing this questionnaire. Athlete Name: Age: Date of Birth: Gender: M / F Weight: Height: Competitive Sport: Classification: ( ) Please describe the nature of your impairment (injury or medical condition): What training phase/season is this for you? Competition Off-season training Off-season not training Please indicate the top level of competition that you have competed in: Provincial (province you live in) National (within Canada) International (Countries other than Canada) On average, how many hours do you train (exercise) each week? 0 5 Hours/wk 6 10 Hours/wk Hours/wk > 15 Hours/wk How would you rate your diet (how healthy you eat everyday)? Not Very Healthy Pretty Healthy (average) Very Healthy Dietary Supplement Use: Do you take any dietary supplements? (e.g. sport drinks like Gatorade, multivitamin, multimineral, vitamins/minerals, protein supplements, sport bars, energy drinks, herbal products, fish oil etc) Yes No 1

2 Dietary Supplement Choices Consider your dietary supplement use over the last 3 months. For each of the dietary supplements listed below, please indicate How Often, Supplement Name, and Reason for Use. How Often: Please place an X in the box that best describes how often you use the supplements listed. Your choices are Regularly (at least twice per week), At Times (you ve tried it or only use it at certain times like during competition or when sick) or Never (you have not tried it or you don t know what this is). Supplement Name: If you do take a supplement please write the exact one in the Supplement Name column if you know it. Reason for Use (Please write the letter that corresponds to your reason or describe the reason if not listed) A. Medical (your doctor told you to) B. Increase energy (so you don t feel tired) C. Increase endurance (how long you can exercise) E. To improve your diet (food F. Improve exercise recovery G. Because others (friends, you eat everyday) (after exercise) family, teammates) do I. Stay healthy J. Enhance immune system (so K. Convenient when hungry or you don t get sick) thirsty M. Increase or maintain muscle N. Enhance overall athletic O. Food allergy/ sensitivity/ mass, strength and/or power performance intolerance D. Someone told you to (coach, parent, friend) H. Enjoy the taste L. Weight loss or weight gain P. Special dietary needs Dietary Supplement How Often (check box) Supplement Name Reason for Use (letter) Multivitamin & mineral Pill Pill with just B Vitamins (e.g. Vitamin B12, Folic Acid, Vitamin B complex, Vitamin B6 Stress Tabs) Pill with just Vitamin C Pill with just Vitamin E Pill with just Vitamin D Other vitamin pills, please list in Name column 2

3 Dietary Supplement How Often Name Reason for Use Pill with just Iron Pill with just Calcium Pill with just Magnesium Other minerals, please list in Name column Vitaminized Water (e.g. Vitamin Water, Aquafina Plus) Protein powder (e.g. whey/soy/hemp/rice) Protein or Sport Bars (e.g. Clif Bar, Power bar, Luna bar, Vector bar) Branched chain amino acids (BCCA) Glucosamine Beta-alanine Glutamine Beetroot Juice/Supplement Buffers (e.g. sodium bicarbonate, sodium citrate) Fatty-acid preparations (e.g. Flax seed oil, omega 3 oil or pill, fish oil or pill) Sport or electrolyte drinks/supplement (e.g. Gatorade, Powerade, Refresh, Nuun, G2, Salt tablets) 3

4 Dietary Supplement How Often Name Reason for Use Energy drinks (e.g. Red Bull, Rockstar, Monster) Caffeine Pills does NOT include coffee (e.g. No Doz) Pre-Workout Supplement (e.g. Cellucor C4) Creatine (alone or in combination) Recovery Drinks (e.g. PureSport Recovery, CytoSport Protein Pure, Boost, Ensure, Breakfast Anytime) Plant extracts/herbal Supplements (e.g. Echinacea, Cold FX, ginseng, garlic, oil of oregano, rose hip, turmeric) Probiotic pills NOT yogurt Sport Gels (e.g. Powergel, Clif shots, Carb- BOOM). Gummy/Bean (e.g. Sharkie, Clif Block, Sport Beans) Other (Any vitamin, mineral, herb, botanical, amino acid, dietary substance, concentrate, metabolite, constituent or extract not listed above.) Please list in the Name column 4

5 Where do you get information about dietary supplements? Please check all that apply. Internet (Websites, Facebook) Pharmacist Naturopath/Chiropractor Medical Physician (Doctor) Sport/Fitness Trainer Family Television Physio/Massage Therapist Health Food Store Print Media (magazines, Coach Dietitian/ Nutritionist books) Product Labels Workshops/Classes Teammates/Friends Other (please list): Which way do you prefer to receive information about dietary supplements? Please check all that apply. Presentations Print media (pamphlets, Individual nutrition Internet (webpages/blogs) books, magazines) consultation (dietitian) Family/Friends Coach/Trainer Health Food Store/Pharmacy Doctor/Chiropractor/Physiotherapist Social media Other: Not interested in information Thank you for taking the time to complete the questionnaire! 5